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Flashcards in pain Deck (36)
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1

mild pain with and without liver damage

Acetaminophen: NTE 3-4 g.
If cirrhosis, 1.5-2 g.

NSAIDs, ASA,

2

moderate pain meds in order of less potent to most potent

1. Codeine + acetaminophen

2. Tramadol- mu agonist, SSRI, NE uptake inhibitor (risk of serotonin syndrome)

3. Hydrocodone + acetaminophen (norco, vicodin, hycet, lortab)

4. Oxycodone + acetaminophen (Percocet)

3

severe pain meds

• Morphine
• Hydromorphone (dilaudid)
• Fentanyl – routes: transdermal patch, IV, transmucosal (need to get extra license for this- stick, lozenges, intranasal)
• Methadone- long half life, QTC needs to be <500
• Oxycodone

4

use Immediate release opioids for...

acute pain- start with short-acting when you start opoioids

5

PK of po opioids

onset at 30 min, peak at 60-90 min, go away at 4 hrs

6

PK of IV opioids

onset 5-10 min, peak at 15-30 min, go away at 2-3 hrs

7

how much should you titrate for mild vs moderate pain

If mild pain, titrate by 25-50% at peak.

If moderate pain, titrate up by 50-100% at peak effect

8

Long-acting opioids good for ...

unrelenting chronic pain (months-years)

9

names of long acting opioids

• Morphine- MS contin, kadian, avinza- q12 hrs
• Oxycodone- oxycontin q 12 hrs
• Fentanyl trans-derm patch

10

dose options for fentanyl patch

o Dose options: 12, 25, 50, 75, 100 mcg/hr
o patches changed q72 hrs

11

onset of action of fentanyl patch

18-24 hrs

12

how does fentanyl reach body through patch

lipid soluble – diffuses thru epidermis subq adipose tissue blood vessels (doesnt work well for cachetic pts)

13

Levy’s principle:

if on 50 mg morphine po for 24 hrs, equivalent to 25 mcg/hr patch

2:1; 50mg morphine/24hrs = 25mcg/hr fentanyl

14

can you give long acting opioids through NG tube or peg?

No • because too big and you cant crush it because that’d make it short-acting

15

what should you also remember to prescribe in addition to long acting opioids

bowel regimen

break through pain: pain that is really severe short-term- immediate release agents

16

how much breathrough immediate release pain meds should you order

• 10-15% of the 24 hr dose can be used as breakthrough

17

Adjuvant pain meds:

• Gabapentin: originally an anticonvulsant
• Pregabalin/lyrica- anticonvulsant
• Amitryptiline- TCA
• Duloxetine- SNRI
• Baclofen- for muscle spasms

18

4 C's of addiciton

• craving, compulsive use, continued use despite harm, consequences d/t use of drug

19

concentration of morphine PCA

♣ 1 mg/ml of morphine in 30 ml IVF solution called TKO (to keep open- the tubing)

20

o Demand: How much they get when the press the button

♣ 1 mg morphine (50-100% of the basal rate)

21

o Lockout: max dose of how much they get-

♣ Q15 min
♣ 4 hr max- 16 mg in this example
♣ reevaluate after 4 hrs whether to adjust the dose

Lock-out at 10-15 minutes. Four hour lock-out 150mg

22

o Basal rate- continuous infusion

♣ Don’t give if opioid naïve
♣ Equivalent to long acting opiate

23

Loading dose- to saturate mu receptors-

o IV bolus of demand or 2x demand dose

♣ 2 mg q30 min (peak effect)
♣ if in acute pain
♣ puts it in to IV directly- faster than thru PCA tubing

24

what to do if someone vomiting up meds?

Convert home opioids dose to IV and make it basal rate.

50-100% of basal rate is demand dose (as breakthrough).

25

tramadol MOA

Mu & 5-Ht/NE uptake inhibitor activity

26

safest drug in liver & kidney failure” –Dr. K

fentanyl

27

Demerol (Meperidine) Rx

postop rigors,

Hem-Onc post-transfusion, not for pain

28

PO morphine pca dose →

660 mg PO/ 24 hrs

29

PCA basal dose = patient’s 24hrs morphine equivalent

660mg PO morphine divided by 3 = 220 mg morphine
divided by 24 ~ 10 mg/hr for basal infusion

30

PCA Demand Dose & lockout

5 mg q 10 mins